


Jason Hickel
16 February 2015

Image: A queue in the former USSR

As an American, I have followed the debate about the future of the National Health Service with curious fascination. I must say I don’t entirely understand why this has even become a question – why anyone seriously thinks that privatizing the NHS would be a good idea, or why we have to resort to citizen campaigns simply in order to keep it around.  As far as I can tell, the NHS is one of the best things Britain has going for it, and it would be a monumental step backward to let it go.

I haven’t always held these views. Being on the left, I have long been committed to the principle of socialized healthcare, but, like most of my countrymen, I secretly suspected that such a system could never really work in practice. Before I moved to London in 2011, I had visions of the NHS as a quagmire of forms, queues, and long waiting times. These assumptions affect US progressives as much as they do devotees of Fox News: they’re in the water, part of the commonsense furniture of everyday life. Somehow we all end up believing that America’s private, for-profit healthcare system is our only hope, and without it we’re likely to end up dying while waiting in line for basic treatment. For most Americans, the specter of socialized healthcare – and of the NHS in particular – looms like the heavy shadow of Russian bureaucracy in a Gogol novel.  

I was forced to confront these assumptions when I made my first visit to the doctor, which I put off for a long time out of sheer fear.  I expected to have to take a train to some government complex where I would submit myself before a nameless bureaucrat behind a glass barrier in a brutalist concrete building. I literally thought this. So I was pleasantly surprised when it turned out that all I had to do was walk five minutes down the road to the nearest GP.

Upon arriving, I went straight up to the counter – no queuing required – and asked to register. Instead of the multiple page forms that I expected to fill out, which I had grown accustomed to completing every time I visited a doctor in the United States, I was presented with a single quarter sheet with the obvious fields: name, date of birth, and address. Nobody asked me for a health insurance card. Nobody asked if I would be able to pay. Nobody asked me for a British passport to prove that I was worthy of care. The edifices of my worldview began to crumble around me.

Fine, I thought: registration may be simple, but surely I’ll have to wait weeks for my appointment? Or even months? I was wrong again. I was given a slot that very afternoon.

I did have to sit in the waiting room, I’ll admit: for a sum total of 15 minutes. During that time, I marveled at the attractive display of public health information lining the walls – something I had never encountered in the US. It struck me, for the first time, that a publically funded healthcare system actually has an incentive to maintain good public health through mass education and preventative care. What a refreshing change from the perverse incentives built into the American model, which not only lacks this motive but operates according to the opposite logic: the more bad health there is in the population, the more money there is to be made from it.

My doctor was warm and professional, set up the referral and ordered my tests, and sent me on my way. As I passed by the receptionist at the front desk I felt almost guilty, and actually stopped to ask her if I needed to pay anything before leaving: surely there must be at least a small fee? She laughed at me. To this day, three years later, I still can’t get used to it, to the idea of health as a public good – it seems too humane to be true.

Some might rush to conclude that this surprisingly positive experience is probably due to the fact that I live in a posh white part of London. But I don’t. I live in Kilburn, and the clinic in question is adjacent to a number of council estates. The vast majority of the clinic’s patients are working class, and only about half of them are white.  The first-rate care I receive is the care that every resident receives, regardless of their race or class – as a basic human right, as part of the social contract, as a feature of the collective solidarity that Clement Atlee’s Labour government forged in the 1940s from the ashes of World War II.

And it’s not just that this clinic happens to be a good apple in a barrel of bad. I’ve been referred to specialists in other units – including large hospitals – on a number of occasions, and each time I’ve found myself amazed at the efficiency of the service.  At one point I was referred for a possible case of melanoma. I was seen by a dermatologist at the first break in my schedule.  So much for languishing in line for treatment.  Why so efficient? Because there’s a powerful incentive at work: the NHS saves money by catching cancer early.

And it’s not just life-threatening illnesses that call forth the best of the NHS. The mundane phlebotomy lab I had to visit recently at the Royal Free Hospital was run like a well-oiled machine, caring for fifty patients an hour at peak time without a glitch.  The system just works. We needn’t rely on anecdotes to prove this. The Commonwealth Fund recently released a report comparing the health systems of 11 highly industrialized countries. In the category of efficiency, the UK ranked number 1. The US, by contrast, ranked last. So much for the theory that profit stimulates efficiency. The UK also ranks well above the US in terms of timeliness of care, contrary to Fox News propaganda.

I suppose I shouldn’t be surprised; while living in the US I spent an astonishing amount of time waiting for appointments and sitting in receptions, even as a paying customer. I sometimes caught myself wondering if things might be different if I were able to pay more.

And it’s not just in the areas of efficiency and timeliness that the UK performs so well. It comes first in almost every other category – equity, access, quality, etc. – making it the best overall healthcare system in the world. As for the overall ranking of the US: dead last, again. The Commonwealth study didn’t measure bureaucracy, but I suspect that here too the UK would win handily.  While living in the States I was regularly frustrated by the amount of time I had to spend not just filling out forms, but reviewing costs, interpreting bills, paying fees, comparing coverage plans, and badgering my insurance company over the phone to shell out for their fair share (an obligation they routinely shirked).  

It’s no wonder that 30% of healthcare spending in the US is absorbed by bureaucracy – nearly twice the proportion that other industrialized countries spend. This is rather strange, given that the chief justification for private healthcare is that it suffers less bureaucracy. It turns out that exactly the opposite is true.

As for how likely a patient is to die for want of life-saving services: I wouldn’t choose to take my chances in the US, given that I’m not a millionaire. A close friend of mine recently discovered she had a fast-growing mass on her ovary that would lead to swift death if it wasn’t removed within the month. It sounds like a no-brainer, but before she scheduled the surgery she had to count the costs: her insurance company agreed to cover 80% (after much pressure from her doctors to get the company to cover it at all), but she would be responsible for the remainder – a sobering $40,000. She’s alive today, but she’ll spend many years working extra hours to pay off the loan she took out just to stay alive.

She is not alone. Millions of Americans are in debt due to healthcare costs, which is the number one cause of personal bankruptcy in the United States. In the UK we don’t have to face this terrible anxiety; it would be difficult for me to overstate how liberating this feels.

These are stories and statistics that I regularly wheel out during conversations with my American friends and family. And while they usually accept the evidence that I offer up (albeit somewhat grudgingly), they always insist that, sure, it sounds like a great service, but there’s no way it can be financially viable, right? But here again the evidence defies assumptions.  The Commonwealth study confirms that the cost the UK pays for delivering the best healthcare in the world is less than any other industrialized nation: only $3,405 per capita. The most expensive healthcare system, by contrast, is the US, at $8,508 per capita – more than double the UK, while delivering much worse results.  

Critics of the NHS claim that we can’t afford to pay for it; but the truth is that we can’t afford not to.

These data tell a clear story. But ultimately it’s not the extrinsic values of efficiency, timeliness, and low cost that make the NHS great. The NHS is great because it’s built on the principles of solidarity, universality, and equality – and because it is staffed by people who believe deeply in its basic moral mission. It is for these reasons that, when the NHS was founded in 1948, the Minister for Health Aneurin Bevan famously proclaimed that it was “the most civilized step that any country has ever taken.”

Yet, tragically, the present government is doing its best to dismantle the NHS, with the ultimate goal, it would seem, of replacing it with the US model. The Health and Social Care Act of 2012 put an end to the mandate for the state to provide comprehensive healthcare to every resident of England free at the point of use, and has allowed for-profit companies to buy up huge chunks of the NHS (£10 billion worth of contracts have already been handed out since the Act was passed).  The Tories know the US system performs worse on every conceivable count, but they are willing to go there anyhow: the healthcare market-in-waiting is just too juicy to leave untapped.

Bevan knew that the NHS would face opposition from powerful private interests, but he was hopeful that it would prevail: “The NHS will stand,” he said, “as long as there are those who will fight for it.” Many Britons are doing just that. But, thanks to skillful government subterfuge, the vast majority do not even know that their cherished healthcare system is under threat, and many others don’t understand what it’s like to live with the dysfunctions of a private alternative.  It’s sometimes hard to realize how good something is until it’s taken away from you. To England, I say, take it from an American: what you have is as good as it gets, and it’s worth defending. Your civilization depends on it.


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